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41 yr old ladyRecurrent episodes of tachycardia
Sometimes terminated by deep breathing
Normal echo
Inputs from Ulhas Pandurangi
The features of the “GOOGLY” 1. Intermittent A-V Block
2. Long RP during 1:1 AV relationship
3. Inverted and narrow ‘P’ waves in inferior leads
4. VAV response on VOD
Hence “GOOGLY” seems to be Atypical AVNRT
( I wear Helmet, always, when Yash delivers)
Why should deep inspiration terminate tachycardia: The manoeuver - Muller is still mulling over
Normal ECG. PES (basal trainS1 + S2) from CS
Blocked His extrasystole
Tachy initiation- RV stimuli initiate tachy with 2:1 AV conduction, followed by 1:1 LBBB tachycardia – Atrial tachycardia or Atypical AVNRT
Atrial activation sequence during ventricular pacing is similar to that during tachycardia ? Atrial tachycardia originating near posteroseptal region or atypical AVNRT
Termination of LBBB, 1:1 AV tachycardia without ‘A’: AT or Atypical AVNRT
HIS PVC did not affect tachycardia – Does not help much
Very early PVC did not affect tachycardia – ORT unlikely
VAV response at the end of entraining VOD - AT ruled out, Atypical AVNRT ruled inAlso PPI-TCL more than 100 ms
300 ms425 ms
75 ms 250 ms
Easy inducibility by narrow QRS tachycardia by ventricular pacing – A clue for Atypical AVNRT, especially when P waves are inverted and narrow ( even in the presence of AV Block)
S2 initiated tachycardia Atrial activation sequence by S2 similar to that during tachycardia
The AV block is infra-His
Deep inspiration -2:1 to 1:1 AV conduction followed by termination during deep inspiration block in the retrograde slow pathway
Deep inspiration again- Vagally mediated tachy termination
Adenosine Both AH ( ) and HA ( ) prolong prior to termination in the retrograde limb.
RF site Activation mapping during tachy. A earliest in rfD
RF energy- Just above CS os. Tachy terminates retrogradely
After ablation – No VA conduction
Final diagnosis
Atypical AVNRT (Fast-slow for the “splitters”) with 2:1 AV conduction
Successful RF ablation of retrograde limb
No retrograde fast pathway conduction